COVER STORY
Pathology 2025:
Imagining the future
Never has medicine been as
challenging as it is in the 21st
century; and never have the
opportunities been so great.
Pathology, as the very foundation of
medicine, is at the forefront of the
revolution and new diagnostic tools
and knowledge are taking
pathologists into broader roles of
research and correlating diagnoses
for clinicians.
Yet, despite the challenges and
opportunities, there remains a
shortage of pathologists which adds
to the pressures to this crucial
branch of medicine. So, what does
the future hold for pathology in
2025? PathWay asked five leading
pathologists from across the globe
to share their vision for the future,
with some fascinating and
surprising results.
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Dr Puay Hoon Tan
change over the next two decades?
technological advances and be fully
involved in and direct new developments,
since it is only appropriate that
pathologists be the ones to control the
use of novel technology in our discipline to
improve patient care.
A. In many institutions with a research
Q. What is your wishlist for pathology
arm, anatomical pathologists are already
serving as the bridge between basic
science and clinical medicine, and are
therefore poised to become effective
leaders in the research arena. I believe
pathology will be increasingly called upon
to take a leadership or at least a
prominent supportive role in research in
the coming years.
over the next 20 years?
Singapore
Q. How will the role of pathology
It is hard to clearly imagine what
advances in information and other
technology will have exploded into our
lives by 2025. It is difficult to use
pathology of 20 years ago as historical
comparison with pathology today, and
extrapolate the advances over the past 20
years to the future two decades, as the
pace of development and change will be
distinctly more rapid in the future.
Hopefully, pathologists in 2025 will not be
merely “tissue samplers. Pathologists
need to keep pace with current
A.
I hope for sufficient pathologists to
perform the closely integrated duties of
diagnostic service, teaching and research.
Pathology is the foundation of medicine,
and is by nature an academic discipline. It
is sad that pathologists have been
sometimes relegated to a less important
role in the medical profession. The goal as
an anatomical pathologist is to provide as
best a diagnosis on submitted tissues, and
to be an effective member of the
managing team of clinicians in solving the
problems of patients. In order to achieve
these aims, pathologists should constantly
add value to their work by actively
participating in teaching and research, as
these are efficient means of learning,
understanding and self-improvement. This
wish can only be realised when there are
enough pathologists on board.
I truly hope that pathology can be reestablished as the basis of all medical
disciplines, and regain the respect,
relevance and profile within the medical
community. It is also important that more
young medical professionals should
consider pathology as a viable career
option, as that will be the start of
alleviating the current shortage of
pathologists. There is a great need for
pathologists with passion for the
discipline.
Technological advances should be
harnessed to continually improve the
discipline, with the pathologist in charge.
Q.
Where would you like to see
research focused over the next 20 years?
A.
I would like to see research focused
on cancer prognostic markers and cancer
cures via targeted therapies. Advances in
molecular taxonomy will be an important
adjunct to histologic diagnoses.
Development of dedicated tissue banks,
construction of tissue microarrays,
standardization of processing protocols so
that paraffinised archival tissue can be
effectively harnessed for
immunohistochemical and molecular
research, all occurring within an
established ethical framework that ensures
moral standards, will be in the future of
research pathology.
Q.
If the current shortage of
pathologists continues, how will the
profession and the community be
affected?
A.
The profession will not be able to pull
itself out of the monotony of service work,
and will not find time to participate in
value added activities such as cutting
edge research, which will be taken over by
non-pathologist scientists. The discipline
will be unable to improve and advance.
There will be a pervasive low morale which
may cascade into a vicious cycle with
diminishing numbers of young doctors
being interested in the discipline. It will
continue to slip in professional standing in
relation to other more glamorous and
dynamic medical disciplines.
Dr Puay Hoon Tan is the Senior Consultant and
Head of Histopathology at Singapore General
Hospital and Adjunct Associate Professor
Departments of Pathology and Anatomy,
National University of Singapore.
Sir James Underwood
United Kingdom
Q.
Which scientific/technological/
medical developments will have the
most impact on pathology in the
coming years?
A. Advances in genetics, information
technology and digital imaging are already
transforming histopathology and many
other pathology specialties. This will
continue. In histopathology, for example, I
predict that much interpretive reporting will
be done from flat screens rather than
through microscope eyepieces.
In my specialty of histopathology, I
forecast that molecular pathology will
develop alongside diagnostic macroscopy
and microscopy and as an adjunct, rather
than as a substitute.
Q. How will the role of pathology
change over the next two decades?
as exciting as forensic death
investigations.
Research in pathology should be
valued by its benefit to human health and
welfare rather than by the size of the
research grant or the impact factor of the
journal in which it is published.
When given death certificates,
bereaved relatives should ask certifying
doctors how they can be so confident
about the cause of death when research
shows that up to 30% of certificates are
significantly wrong or incomplete? How
about an autopsy?
Pathology services should cease to be
regarded as a ‘cost’ or ‘overhead’ in
healthcare organisations.
Pathology investigations should be
evidence-based in order to reduce
unnecessary tests and iatrogenic anaemia
(resulting from excessive haematological
and biochemical investigations).
A.
Pathology will always to be the
scientific basis for medical practice, but it
will continue to struggle to get this
message across to curriculum planners
and to health service managers.
The migration of some pathology
‘tests’ from laboratories to the point-ofcare will continue, but hopefully with
concerns about training, health and safety,
quality assurance, and results
interpretation fully addressed. This will be
best achieved by point-of-care testing
being part of a locally managed pathology
network.
Medical graduates (as opposed to
science graduates) working in pathology
services will continue to develop a much
more patient-centred approach to their
specialty, with increasing involvement in
clinical decisions as members of
multidisciplinary teams.
Q. What is your wishlist for pathology
over the next 20 years?
A. Pathology should be restored to its
rightful place in the medical undergraduate
curriculum before widespread ignorance
and misunderstanding imperils patients, if
it has not done so already.
Television drama producers should
realise that cancer diagnosis can be just
Q.
Where would you like to see
research focused over the next 20
years?
A.
Rather than suggest topics for
research, I would argue for a cultural shift
in how pathology research is designed,
conducted and published. Too many
papers report small series with numerous
variables, such that the study is incapable
of advancing knowledge with sufficient
reliability. To give pathology research the
status it deserves, we should encourage
studies that are robust, powerful and
demonstrate clinical effectiveness. For
example, a new classification or grading of
a particular disease should be researched
as a clinical intervention in order to
determine the effect on patient outcomes.
A new monoclonal antibody for identifying
histogenetic or predictive markers should
be evaluated for its actual clinical utility.
Sir James Underwood is Professor of Pathology
at the University of Sheffield, UK, and
consultant histopathologist to the Sheffield
Teaching Hospitals. In 2002, he was elected
President of the Royal College of Pathologists.
He was recently knighted for his services to
medicine.
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COVER STORY
Dr Lee Hilborne
saying this for years and it won’t happen
over the next 20 years. I am not sure how
USA
Q. Which scientific/technological/
fast change will occur. Of course, if the
demand for pathologists rises and the
shortage increases, the laws of supply and
medical developments will have the
most impact on pathology in the
coming years?
demand will necessitate that the cost of
A.
encouraged to enter the profession.
professional pathology services will
increase and more individuals will be
Molecular diagnostics, genomics and
proteomics will probably have the biggest
impact because they will continue to
redefine disease at the molecular level.
Some of the challenges we face today in
terms of discriminating disease will be
eliminated ie: uncertainty will be
decreased and accuracy will be increased.
The further development of
nanotechnologies will also drive change
and expedite diagnoses. The other change
will be increased automation - more things
can be done with greater consistency, less
time, and less cost.
Dr Lee Hilborne MD, MPH, DLM (ASCP) is
Professor of Pathology and Laboratory
Medicine at the David Geffen School of
Medicine at UCLA and Deputy Director of
Global Health for the RAND Corporation in
Santa Monica, California.
Q. Where would you like to see
Q. Which scientific/technological/
research focused over the next 20 years?
medical developments will have the
A. I think research should focus on new
most impact on pathology in the
diagnostic tests, getting those tests with
promise to market, and work on modifying
some diagnostic tests that are only
available in large clinical laboratories
because of the testing complexity. Highly
complex testing restricts applications to
developed countries and those with
resources. Moving to new paradigms for
some diagnostics, particularly for such
conditions as acute infectious diseases,
HIV, diarrheal diseases, acute respiratory
illnesses, can help move those diagnostic
services to under-served areas of the
world. Of course, the development of new
diagnostics will require the availability of
therapeutic techniques for treatment once
the diagnoses have been made. Of
course, I would hope that by the next 20
years we would have the answer regarding
how to effectively attack both
malignancies and retroviral infections.
Current trends have been in the opposite
direction, but shortages will force a
reversal of this trend.
Anthony J Landgren, FRCPA, FACLM, MRACMA,
Barrister and Solicitor. Tony Landgren is
Chairman of the Department of Anatomical
Pathology at the Royal Melbourne Hospital and
a Biotechnology Lawyer.
Ireland
Australia
Q. Which scientific/technological/
coming years?
A. Further development of molecular
diagnostic tools and point of care
pathology testing.
Q. How will the role of pathology
change over the next two decades?
A. Increased focus on disease
prevention and early diagnosis.
Q. What is your wish list for pathology
over the next 20 years?
A. Short to medium term issues,
particularly work force shortages tend to
overwhelm consideration of where to in
the next 20 years. Improved training
opportunities, facility and technology
and error reduction are my current
priorities.
A.
research focused over the next 20
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A.
Pathologists, laboratories and
diagnostic activities will be predominantly
located in major population centres with
point of care testing, courier transfer of
specimens and electronic communication
of results. This has already happened with
many regional communities no longer
served by a locally based pathologist.
Dr Anthony Landgren
pathologists continues, how will the
profession and the community be
affected?
I guess that depends on the other
issues. I think the demand for traditional
surgical pathologists may decrease if
molecular diagnostics take over. Many will
argue (and I agree) that people have been
If the current shortage of
pathologists continues, how will the
profession and the community be
affected?
Dr D Sean O’Briain
investment, improved risk management
Q. If the current shortage of
Q.
Q. Where would you like to see
years?
A. Development of molecular diagnostic
tools.
medical developments will have the
most impact on pathology in the
coming years?
A.
Medicine is pathology, and as new
technology steadily changes medicine,
pathology will change gradually with it. A
sudden quantum change in medicine,
rather than gradual change, is less likely to
occur but there are two possible
circumstances of rapid profound change.
One is the finding of a silver bullet, a magic
cure for a major disease, such as a cure for
cancer, that would profoundly change
much of medicine including pathology; but
this is unlikely to be achieved by 2025. The
second is the emergence of a devastating
new disease. We worried about this with
SARS a few years ago, and within the past
two decades we’ve seen AIDS change the
face of medicine in many poorer regions of
the world.
Extreme regional poverty,
overpopulation and local conflicts with
ensuing malnutrition and infectious diseases
including gastroenteritis, AIDS and
tuberculosis, will continue to be the major
problems in world health but, as now, will
only have a significant effect on medicine of
the developed world if the situation also
acts as a pressure cooker for the
emergence of new global pandemics.
Developed countries may heave a quiet
collective sigh of relief if 2025 dawns
without such a pandemic, but, as now, are
unlikely to take effective action to end the
threat.
In the developed world, pathology will
still use many of the current techniques
but these will be enhanced due to
developments predominantly in molecular
pathology, information technology and
imaging techniques and will be driven by
commercialisation of new techniques and
better instrumentation.
Q. How will the role of pathology
change over the next two decades?
A.
The pathologist will continue as
diagnostician, but as there will be a wider
range of technologies to support and to
augment the diagnosis, will take on a
larger role in correlating the diagnosis for
the clinician. A major challenge to the
pathologist will be to master the new
technologies and to incorporate them into
the pathology diagnosis. The current
division of the pathology laboratory into
traditional well-defined subsections may
be a barrier to change; with expanded
dynamic imaging and point of care testing
much of current laboratory work will occur
at the bedside while the laboratory will
offer a new profile of tests that may require
a realignment of diagnostic disciplines and
subspecialties.
Enhanced decision support
programmes will be a major component of
clinical care and the pathologist will format
results to feed laboratory information into
these hospital systems. This will simplify
the diagnosis and care of well-defined
diseases and will allow the pathologist to
focus on diseases where the diagnosis is
obscure. These will be the subject of
hospital multidisciplinary conferences
where the pathologist will have a major
role in defining the implications of complex
laboratory results.
New therapies will change the profile of
diseases, and some now-fatal diseases
will be curable; but just as infectious
diseases did not go away when antibiotics
were developed, diseases such as cancer
will develop new forms of resistance to
therapy and complications from the new
treatments. New laboratory-based
approaches to these problems will
continue to emerge.
Q. What is your wishlist for pathology
over the next 20 years?
A.
The role of the pathology laboratory
is to use blood, fluid or tissue to provide
accurate, timely and relevant information
useful in making diagnoses, and to guide
and monitor therapy. A general wishlist
includes more rapid access to the
specimen, increasingly better tests and
prompt communication of the results to
the clinician. These will be achieved by a
variety of developments in test ordering,
point of care testing, specimen transport,
with enhanced laboratory information
systems connecting with more developed
electronic patient records, and new
instrumentation providing better, faster
tests.
Q.
Where would you like to see
research focused over the next 20 years?
A.
Research should be focused where it
is it likely to do most good, either on
diseases causing widespread morbidity or
where a breakthrough seems intuitively
likely. The major areas include infectious
diseases that involve the developing world,
cancer, cardiovascular disease and
degenerative cerebral disease. We are
likely to see a huge return on money
invested in research on infectious disease
and cancer, based on application of
molecular biology. But the causes of
cardiovascular and degenerative cerebral
disease remain tantalisingly out of reach
and will require a substantial research
effort at a more basic level.
Q.
If the current shortage of
pathologists continues, how will the
profession and the community be
affected?
A. Pathology, like any other occupation,
follows the law of supply and demand.
Shortages are likely to be temporary and
regional. Medical graduates are unusually
mobile and will move to the areas of
opportunity. Pathologists will improve the
profile of the discipline and present it more
attractively to medical students who will
respond to the increased career
opportunities by filling any vacancies.
Dr D Sean O’Briain MB, MRCPath, FFPath,
FRCPI is the Dean, Faculty of Pathology, Royal
College of Physicians of Ireland, Associate
Professor of Pathology, Trinity College Dublin
and the Consultant Histopathologist and Head
of Department, St James’ Hospital, Dublin,
Ireland.
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